The fatal omission of contraception
The recent Lancet Series on Maternal Health confirms a well-established reality: the majority of preventable maternal deaths continue to occur in areas affected by humanitarian crisis, largely as a result of poor maternal care. But this reminder is also accompanied by a chronic offense. Contraception, one of the most effective interventions to prevent maternal death and disability, is not given the spotlight it deserves.
There is no dispute, by authors or anyone, that contraception is critical. But overlooked is the fact that comprehensive contraception in crisis contexts can meaningfully reduce the immense burdens on strapped health systems over time. This will only happen if we conscientiously, significantly, and practically increase the attention paid to contraception now.
According to a global evaluation, the provision of comprehensive contraception in emergencies has only marginally improved over a decade. It remains one of the leading gaps in reproductive health services in emergencies. Consequently, it is out of the grips of millions who need it now. This includes, for example, women and girls mired in humanitarian crisis in northeast Nigeria, where estimated rates of modern contraceptive user can be as low as 3%.
This brings us to the critical question: how is it that one of the most cost-effective interventions to prevent maternal death remains absent to those who need it most?
The answer is not that the service is not desired by women in crisis settings. Before the IRC opened its reproductive health clinic in Borno State, Nigeria, women and girls were already asking for contraception. Most women were asking for implants, which can provide up to 5 years of protection from unintended pregnancy and can be removed at any point with a near immediate return to fertility.
In places as diverse as Khyber Pakhtunkhwa province in Pakistan, along the border between Myanmar and Thailand, and eastern Democratic Republic of Congo, women are choosing IUDs and implants even though those services were almost non-existent just a few years ago. As soon as contraception services were introduced, the latent demand became obvious.
So if it is not the fact that women will not use the service, what is it? In many countries, high rates of maternal mortality and low access to reproductive health services are often pre-existing symptoms that become exacerbated by conflict. But the unwelcomed reality is that the very people seeking to help are perpetuating these vulnerabilities.
Only 14% of funding appeals for reproductive health included family planning. The Inter-Agency Working Group for Reproductive Health found that long-acting or permanent methods of contraception were rarely mentioned. In terms of funding, countries suffering from conflict tend to receive 57% less funding for reproductive health than non-conflict countries.
Inaction and lack of will is no doubt exacerbated by the fact that the minimum standards for reproductive health in emergencies, the international guidelines that outline the necessary package of basic services, exclude comprehensive contraception as a priority at the onset of emergencies. This omission has implications for what donors will fund and what supplies will make it into pre-packaged emergency kits. So despite the fact that women and girls in northeast Nigeria have a high demand for implants, no pre-packaged emergency reproductive health kit contains them. IUDs are provided in very limited quantities in these emergency response kits, based on forecasts that just 5% of clients will choose the method. This sets services behind the curve of what is possible, before we even try.
Contraceptive choice must be a priority at the onset of emergencies, including long-acting methods. Donors must demand that this life-saving intervention is included in any emergency reproductive health response, just as they would require bednets or malaria treatment in many of the countries suffering from the highest rates of child mortality. Implementing agencies must stop claiming to address the maternal health needs of women and girls in humanitarian crisis while neglecting contraception. As the minimum standards undergo revision, this fatal omission must be addressed.
And it is also worth noting again that the consequences of this omission are not limited to maternal health. We risk missing an opportunity to provide women with what they actually want, which is a transformative element of control over their life amidst chaos.
The international community must reposition contraception if it is to uphold its commitments to the health and wellbeing of women and girls affected by crisis. The time to provide contraception is not when situations stabilize, or when international guidelines catch up, or when contraception has a prominent enough spotlight in the next maternal health series. Everyone in these respective areas must do their part to reposition contraception and accelerate this process.
But ultimately we should keep in mind that the women and girls that we serve don’t have the luxury to wait, and neither do we.
Ashley Wolfington is a Senior Technical Advisor for Reproductive Health at the International Rescue Committee based in New York. This blog first appeared in the Lancet’s Global Health Blog.
The International Rescue Committee responds to the world’s worst humanitarian crises, helping to restore health, safety, education, economic wellbeing, and power to people devastated by conflict and disaster. Founded in 1933 at the call of Albert Einstein, the IRC is at work in over 40 countries and 26 U.S. cities helping people to survive, reclaim control of their future and strengthen their communities.